Instructions for completing the Application for Refund Form Complete Questions 1 through 4 and include the Case Caption on the top left of parenthesis. 1. A. Fill in the amount of the refund and the party name include if plaintiff or defendant. B. Fill in the Civil Action No. C. Fill in the reason for request. 2. The payment Agency Tracking ID will be found on your electronic receipt from Pay.gov or your Notice of Electronic Filing (NEF) email as the Receipt Number. Transaction Date is the date of charge. 3. Check the type of credit card used for payment. 4. Fill in credit card number and expiration date. Confirmation email - (Anyone who is responsible for your accounting may also receive this email) Signature - MUST be of Attorney of record that is on the document for refund. Enter complete address and phone number. Instructions for CM/ECF submission of Application for Refund Form # # # # From the Civil Tool Bar Go to Other Filings - Select Other Documents From the Drop Down Menu Select - Application for Refund (To be filed at 2:07-mc-203) Follow screen instructions You will receive a Confirmation Email once the Refund has been successfully processed. American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT WESTERN DISTRICT OF PENNSYLVANIA ) ) ) ) ) ) ) Misc No. 07-203 Application for Refund of Fees Paid Electronically Through Pay.Gov I, the undersigned petitioner, under penalty of perjury under the laws of the United States of America, declare (or certify, verify or state) that the following statements and information are true and correct: I understand I should contact the United Stated District Court, Western District of Pennsylvania for a refund and do not contact my credit card company for a refund. 1. Please complete the application below: A. I am petitioning to receive the total amount of $________________, which is the sum of the overpayment of filing fee for the document filed in the abovenamed case on behalf of: ______________________________________________________________ ______________________________________________________________. Civil Action No._____________________ Reason for Request ______________________________________________ ______________________________________________________________. Transaction Date: ____________. B. C. 2. Payment Agency Tracking ID: _____________, (Payment Agency Tracking ID number is located on your confirmation email from Pay.gov or your NEF email as the Receipt number) 3. Please indicate which credit card was used to issue a refund: G G G G G American Express Diners Club Discover Master Card Visa 4. Card number_________________________________Expiration Date_______________ Date of Request: __________________________ Email Address_________________________________________________ (Your confirmation Email for refund will be sent to this address) Signature: ___________________________________________________________________________ Name of Applicant (Please type or print) ________________________________________________ Complete Address of Applicant and Phone Number (Please type or print) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com